Patient satisfaction has come full circle. Why you need to care.

I get it. It is a little strange. In fact, some people even think I’m crazy. Why? I’m a physician, but in my free time, I love helping my colleagues improve their patient satisfaction. Lately, I’ve spent a lot of time discussing a patient satisfaction survey known as CG-CAHPS (Clinician and Group Consumer Assessment of Healthcare Providers and Systems). I’m sure it doesn’t surprise you to learn that CG-CAHPS is a topic that produces little excitement. In fact, if you ever want to end a party early, start talking about patient satisfaction. I understand, but like I tell my coworkers, patient satisfaction is here to stay. So if you can give me a couple minutes of your time, I’ll give you 3 things you can do today to begin improving your patient satisfaction.

What is CG-CAHPS?

CG-CAHPS is a standardized outpatient survey that various organizations, including Medicare, are using to assess your patients’ experience with the clinic visit. In case you’re wondering, the terms patient satisfaction and patient experience are often used interchangeably. In reality, they are intended to be different. For example, if you diagnose Mr. Thomas with diabetes, he won’t be happy, but he can still be satisfied with the overall clinic experience. The CG-CAHPS survey tries to differentiate the care experience from the patient’s emotions. This is helpful because it’s easier to improve an experience.

There are seven questions on the CG-CAHPS survey that specifically relate to you, the provider. When your patients complete the survey, they are asked to rate you in these seven categories.

Did this provider explain things in a way that was easy to understand?

Did this provider listen carefully to you?

Did this provider give you easy-to-understand information about these health questions or concerns?

Did this provider seem to know the important information about your medical history?

Did this provider show respect for what you had to say?

Did this provider spend enough time with you?

Using any number from 0 to 10, where 0 is the worst provider possible and 10 is the best provider possible, what number would you use to rate this provider?

When the scores are reported, you only get credit for the most favorable response. For example, if the survey gives your patients three choices (yes, definitely; yes, somewhat; no), you only get credit for the number of patients who choose the highest score (yes, definitely).

Why should you care?

As physicians, we all want to improve the care we provide our patients. This is what we do every day, so we don’t need a survey to make us do the right thing. However, the Affordable Care Act has increased the stakes by requiring physicians to use the CG-CAHPS survey to assess the patient experience. The requirement initially only applies to certain physician groups, such as those participating in accountable care organizations.

However, the eventual goal is that all providers who participate in fee-for-service Medicare will measure their patients’ experience with the CG-CAHPS survey. Once the survey is implemented, the next step will be to link the survey responses to reimbursement through the physician value-based payment modifier. The modifier is a way for Medicare to tie pay to performance. Doctors who perform well on certain quality and patient satisfaction metrics will be paid more than those doctors who do not. How will patient satisfaction be measured in this program? You guessed it: through CG-CAHPS.

Begin working to improve your patient satisfaction now. For starters, follow the 3 tips listed below. The infiltration of CG-CAHPS and its effect on reimbursement is right around the corner. You do not want to be caught unprepared.

1. Learn as much as you can about the CG-CAHPS survey. There are several books, articles, and websites about CG-CAHPS. Pick one and begin learning all you can.

Patient satisfaction has come full circle. Why you need to care. 17 comments

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SteveCaley

I offer that this enterprise is fascistic, and anti-science. The principles of scientific reasoning are discarded in the manufacture of this thing. When something is purported to be constructed under the principles of rubrics, but instead is constructed for a different and unspoken purpose, the intentions behind the construction are suspicious.
Let’s look carefully at this in summary. Patient satisfaction is obviously a component of delivering medical care. An unknown committee has assembled a complex algorithm that produces a number, or set of numbers. A competition begins to do what is necessary to maximize the numbers, not to improve patient care as an entity. Those who are able to compete most efficiently “win” in the rat maze; those who do not, “lose.” Instructional materials are sold and offered to

Trina

Steve,

Thanks so much for your comment. You definitely share the frustration of many providers I work with as well in terms of the survey construct and methodology. Everyone always asks me why, despite this, I love spending my free time helping providers with patient satisfaction. I think my passion for this comes from a couple of different places. First, I’ve had coworkers who become so frustrated by these surveys that they want to leave medicine. I hate hearing that, so I always do whatever I can to prevent that from happening. I think we all agree that a survey should never be used to drive a good doctor away from medicine. I always encourage them to think back on why they became a physician in the first place. For me, it’s because I truly wanted to take care of my patients and improve their lives in some way. I honestly believe that being ill can be one of the scariest times in life. One of the things we can do is make that experience as positive as possible, and I believe that extends beyond simply providing medical treatment. I tell my co-workers not to focus so much on if their score is an 87 or 92, but on what they can do each day to make the experience better for their patients. I find when our docs do that, they are much less frustrated by the actual survey, and they really focus their efforts on improving the patient experience because that is what they wanted to do all along. I also advocate for the docs when I meet with our c-suite and leadership team to ensure they understand the limitations of the survey. The final thing I point out when speaking with docs is that no survey is perfect. I certainly advocate for increased discussion about the survey and working to improve it. However, I think if we wait until we have a perfect survey before taking action, we will never move. In the end, we are all going to become intimately familiar with health care if we have not already done so. At some point, we, or our parents, relatives, siblings, partners, or children will become ill and have to enter the health care system. When this happens, I will certainly want clinical competence as my top priority. However, I truly hope the people caring for me also have a passion for patient satisfaction and the patient experience. In the end, although the survey may change, I definitely feel Medicare has spoken, and I do not think it will disappear completely. Thus, I tell the docs I work with that although I cannot make the survey go away, I will certainly do what I can to help them improve their patient satisfaction.

But the underlying principles of the rubric – the construction of a survey to somehow represent an evanescent thing – is what bothers me the very most. There are things that cannot be quantitated, and things that we ought not to pretend to quantitate.
For instance – However, I truly hope the people caring for me also have a passion for patient satisfaction and the patient experience. Why is the experience so fragmented that it is left to hope? That a mathematician from afar must create algorithmic contraptions to measure what should be made patently present and immediately responsive in the encounter.
Secondly, As much as kind words and encouragement may help, verba volant, scripta manent words fly by, pass by – what is written, remains.
” I tell my co-workers not to focus so much on if their score is an 87 or 92, but on what they can do each day to make the experience better for their patients.” Nevertheless, what exists forever in the database in Washington is that you are an 87-grade physician, not a 92-grade physician, kind words or not.
” In the end, although the survey may change, I definitely feel Medicare has spoken,” ja vohl, so this conversation is entertainment for the troops only. ” I think we all agree that a survey should never be used to drive a good doctor away from medicine.” Naturally. We just had to reorder the value of “good doctor,” as is often done in propaganda exercises. Once we establish conformity of the good doctors, we will have achieved – that thing we are working towards. That thing. Whatever it is, but we are sure it is better.

LeoHolmMD

Increasingly, the unquantifiable is frankly ignored. Bludgeoned by obsessed metricizing. This is why “health” remains elusive in a system spending billions to achieve it. Depression is pervasive despite being awash in PHQ-9s and SSRIs. People wonder where the joy in their life went. It has no number associated with it, so it doesnt exist. I await the results of the Meaningful Interaction with Humans Committee Survey. Perhaps things will change then.

SteveCaley

Thanks, Leo. Paradoxically, numbers are the emotional refuge of people in a society (sorry!) that is innumerate and suspicious of the intellect.
I oversaw a large contract which specified the delivery of certain medical services. I approached it with the odd and lonely concept that I should be objective and accurate, and give useful feedback. It’s part of the Western spirit, I guess, to ride the range alone.
Before testing, I set the parameters of 95% certainty that an 85% outcome in testing would be within 5 percentage points of the true result. The 95% was arbitrary, as was the 5 percentage points; the 85% was specified in contract.
If the contractor fell below 80% in a certain metric, I would fine them. I calculated the number of charts that I needed to review in each criterion, and gathered the data for my team; did the audit, and submitted it.
Boy, what a windstorm hit from that!•
•In one area, I could only find three relevant charts, and found compliance in two of them.
•In other areas, we tested up to the target, and found such things as 83% compliance.
•When I was sure of my pre-defined metric, I fined them for noncompliance.
The innumerate leadership shrieked. “This one’s 66.6667% – it should fail! And that one’s 83% – it should fail too!”
My explanations could as well have been in Swahili, for all they were sinking in. We are, in fact, the CUSTOMER, and we have no obligation to be “FAIR” in this matter. I was accused of spinelessness, and even dishonest favoritism by the managing primates.
As Douglas Adams pointed out, the answer of the riddle of the universe is 42. We’re not sure what the question is.
But the way business is done these days, the Contractor cowers before the Customer, who is Always Right. To justify frank sadism, we use recourse to numbers, as our superstition is that Numbers are Right. Nobody understands the statistician’s world, where a vast majority of observations cannot be even ranked; those that can may not be quantitated; those that can may not map proportionately to what is being measured; and certainly not diffeomorphically (I never get to use that word, so here it is.)
Numbers allow us to pretend that what is ignorance, sadism and intimidation, somehow has recourse to the Real World and is therefore justifiable.
Yay.

DeceasedMD

How is it that people did their jobs 20 years ago? There were no “likes” or “dislikes”. You sort of inherently knew if you are doing a good job with ones clinical skills and judgment. All of this undermines the pt doctor rel’n as we know it. It also is bad for any business if it always depends on customer “likes”.

SteveCaley

Absolutely – and when we had societies and towns and villages, the word got out – maybe unfairly and mean-spirited, but no worse than Press-Gainey – that you should go see Dr. Bob for good patient care, but that nasty old Dr. Fred for surgery – he’s a jerk but a good surgeon – etc.

“You know, comrades,” says Stalin, “that I think in regard to this: I consider it completely unimportant who in the party will vote, or how; but what is extraordinarily important is this — who will count the votes, and how.” Boris Bazhanov’s Memoirs of Stalin’s Former Secretary, 1972

DeceasedMD

I love the Stalin quotes. Fits well in our present society. And really enjoy all your most crafty posts.

SteveCaley

Thankya!

Peter Elias

Here is how I encouraged my colleagues and the staff in my office to respond to our institution’s efforts to improve patient satisfaction scores.

Thanks for the post. I enjoyed reading it as well. I definitely think there will be increased interest and focus on improving the patient experience. I think you’re approach is good in telling your physicians to spend more time focusing on being good doctors and less time worrying about the survey. In the end, patients just want providers who are able to demonstrate that they care. For another great post, check out the post on this site from July 31:
Getting personal with patients really matters by Dr. Imamu Tomlinson.

Trina

Margalit,

Thanks for your response. You raise valid concerns which is one of the reasons a lot of organizations have moved from the 12 month survey to the visit survey. I’ve included a link here about the visit survey, https://cahps.ahrq.gov/surveys-guidance/cg/visit/index.html. This survey asks the patient to reflect on their most recent visit, so it ties back to the provider they just saw. Although some of the questions on this survey still relate to a 12 month time frame, the questions about the provider relate to the most recent visit. On this version of the survey, those questions have a 3 point scale of “yes, definitely”, “yes, somewhat”, and “no”.

Excellent article! Thanks for contributing your knowledge. Of course, I know some people have issues with patient satisfaction surveys. The surveys aren’t perfect, but they are a step in the right direction. Over time, they’ll become more and more fine tuned. However, in the meantime, they do give us information and direction . Thank you again for writing this helpful article. My best to you.

I can understand the frustration of healthcare providers with the very idea of surveys to rate patient satisfaction. However, providers need to see the patient’s side as well and ask themselves what has happened in medicine to make these surveys necessary – and you cannot blame it all on corp med. When you are asking patients if doctors are listening to them and respecting what they have to say, then clearly there is a problem and everyone involved should want to make the system work better.

Trina

Karen,

Thanks for your comment. I definitely agree with you. These are some of the very characteristics I focused on when I chose my personal doctor, and I am so happy I did. She is wonderful.

Thanks for writing. I definitely think the visit survey can be used to improve the patient experience. One nice thing about the visit survey is the patient is asked to focus on the provider they most recently saw, as opposed to providers from the past 12 months. Like all surveys, I think the results can help to lead you in the right direction, but I still think your organization has to do a deeper dive to truly understand where your areas of opportunity lie. The survey requires the patient to answer pre-defined questions with set responses, so you will only get limited information from the actual questions. One place to start getting more detailed info to actually drive improvement is through the comments patients write in conjunction with the survey. Beyond that, you’ll probably have to work with your focus groups and patient advisors to truly understand your root causes.